Comparing the effect of sexual counseling based on BETTER and PLISSIT models on sexual assertiveness in women with breast cancer after mastectomy

Abstract

BACKGROUND:

Sexual changes in breast cancer occur after diagnosis and treatment, including a mastectomy. Sexual assertiveness is an effective factor in sexual satisfaction, which means the ability to convey sexual feelings, beliefs, and thoughts. Given the limited studies on sexual assertiveness in breast cancer and different client participation, this study was conducted to compare the effect of sexual counseling based on two models of PLISSIT (Permission, Limited Information, Specific Suggestion, Intensive Therapy) and BETTER (Bring Up, Explain, Tell, Time, Education, Record) on sexual assertiveness in women after mastectomy.

MATERIALS AND METHODS:

This quasi-experimental intervention was conducted in 2021 in Mashhad, Iran. Seventy-eight mastectomized women with breast cancer were assigned to the BETTER (n = 39) and PLISSIT (n = 39) groups using permuted block randomization with a block size of 4 and an allocation ratio of 1:1. Both groups received four individual counseling sessions, one week apart. The research tools included a demographic information form and the Hulbert index of sexual assertiveness. Changes in the mean scores of sexual assertiveness between the two groups were evaluated before and four weeks after the intervention, and the mean changes were compared between the groups. Data analysis was conducted using the Kolmogorov-Smirnov test, independent t-test, paired t-test, and Chi-square tests using Statistical Package for the Social Sciences (SPSS) version 25 (P < 0.05).

RESULTS:

The results of the study showed that before the intervention, there was no significant difference in the score of sexual assertiveness in both groups (P = 0.253). The mean score of sexual assertiveness changes before and after the intervention in the BETTER group (8.07 ± 4.9) was significantly higher than in the PLISSIT group (5.58 ± 4.7) (P < 0.001).

CONCLUSION:

The results indicated that BETTER sexual counseling was more effective in increasing the sexual assertiveness of mastectomized women than PLISSIT counseling. Due to its simplicity and client-centeredness, this model can be used in breast cancer care programs.

Introduction

Sexual changes in breast cancer occur after its diagnosis and treatment, including mastectomy, and are affected by various factors, such as decreased sexual desire, fear of body deformity, fear of rejection by a sexual partner, and sexual dissatisfaction.[1]

The World Health Organization has emphasized individuals’ empowerment for improving health.[2]

Sexual assertiveness is an effective factor in sexual satisfaction, which means the ability to convey sexual feelings, beliefs, and thoughts and to defend sexual rights logically.[3] Alberti and Emmons (1970) defined sexual assertiveness as individuals‘ ability to act on and stand up for their interests without anxiety and to express their rights without violating others’ rights.[4] Sexual assertiveness is defined as a psychosocial feeling about individuals‘ perception or interpretation of how their feelings are expressed in marital relationships. Sexual assertiveness is regarded as individuals‘ ability to have sex to meet sexual needs and to guide sexual behavior with their spouses.[5]

Asadi (2011) found that sexual assertiveness was a significant factor in sexual and marital satisfaction.[6] Mirshamshiri (2015) found that increase in sexual assertiveness decreased marital conflict and burnout.[7] Examination of the role of sexual assertiveness in women‘s sexual desire, Hurlbert found that women with high sexual assertiveness had higher sexual activity, orgasm, sexual satisfaction, and marital satisfaction.[3]

Difficulty in communicating and expressing needs and wants is the main cause of sexual and relationship problems after cancer treatment. Akbari et al.[8] (2020) indicated that sexual assertiveness was a major factor in sexual satisfaction, and since the sexual activity pattern was unsatisfactory in most women with breast cancer, their sexual assertiveness was also low. Studies indicated that both women and their sexual partners used the silent method for coping and compliance and even avoided telling healthcare providers about sexual issues.[9]

Yusuf et al.[10] (2013) found that women had changes in their perception of their body image owing to breast loss and changes after surgery, considered themselves incomplete and unattractive, and worried that their husbands would reject them due to the changes. If women talk to their sexual partners about their conditions, abilities, disabilities, and limitations after completing their cancer treatment, and in other words, obtain their sexual assertiveness, they will be able to manage changes in sexual relations easily and better.[9]

It is not easy to express sexual problems in Iran because of cultural and religious reasons, so the existence of these problems occurs secretly in daily behaviors in the form of unnecessary anger and family conflicts.[11] Khajehaminian et al.[12] (2014) conducted a study to identify the sexual function of women after mastectomy. The results showed that Iranian women consider sexual and intimate relations as one of the factors in maintaining the foundation of the family and therefore try to meet the needs of their husbands. In fact, they respond to new sexual situations in two possible ways: by refraining from sexual intercourse or accepting sexual intercourse with undesirable changes caused by mastectomy.

Studies demonstrate that lower sexual assertiveness is associated with higher marital incompatibility, psychological distress, and emotional divorce.[7] Taheri (2020) found that higher sexual assertiveness decreased emotional divorce.[13] Cancer patients, regardless of gender, age, and type of cancer, need to receive sexual health services, and access to sexual health services should be provided for these patients. Therefore, recognizing the sexual health needs of patients with cancer can help to remove barriers and provide sexual health services for them in the health system.[14]

Therefore, the design and implementation of a counseling-educational method are essential to promote sexual relations and intimacy in women with breast cancer.

The PLISSIT model (Permission, Limited Information, Specific Suggestions, and Intensive Therapy) has been widely used in sexual counseling.[15] The BETTER model is another approach to sexual counseling in cancers.[16] and consists of six stages as follows: The first stage (Bringing Up): discussing the issue of sexual relations with the patient. The second stage (Explaining): counseling on the importance and impact of sexual issues on quality of life. The third stage (Telling): informing and explaining sexual problems. The fourth stage (Timing): paying attention to scheduling. The fifth stage (Educating): educating about changes in sexual function due to cancer and its treatments and recognizing and correcting misconceptions. The sixth stage (Recording): recording important aspects of discussions, evaluations, and interventions.

The PLISSIT model is a simple way to address sexual issues. One of its benefits is allowing one to express sexual concerns freely in the first stage, which examines sexual problems at the outset of counseling without marginalization. In fact, it is a simple way to address sexual issues[17]; however, it has a linear format, and due to entering from one stage to another, the therapist cannot recognize that it may be necessary to return to the previous stage to address the patient‘s sexual concerns. This model places little emphasis on patient feedback. A limitation of the model is that due to the need for knowledge and skills at the third and fourth levels of PLISSIT, midwives and nurses can only intervene in the first and second stages.[15,18]

On the contrary, the BETTER model is defined as a client-centered model and is a tool to facilitate the express of sexual issues between the client and the therapist. Martinez (2007) maintains that this model has been introduced owing to its simplicity and focus on improving sexual discourse. The emphasis of the BETTER model is on recording conversations to expand and advance the sexual discourse. This model provides a wider range of sexual negotiations based on the client‘s schedule and necessary information.[16,19]

Studies related to using the PLISSIT and BETTER model in the postpartum period,[20] infertility,[21,22] and some chronic diseases[23] have been done, but so far, there is no research comparing these two models in the field of sexual assertiveness in patients undergoing mastectomy due to cancer. Considering the cultural beliefs of Iranian society about the difficulty of talking about sexual function problems, especially after changes in the appearance of sexual organs and the client‘s participation in these two models, and the contradictions about the performance of the PLISSIT model and on the other hand the simplicity of the BETTER model, the researcher aimed to conduct research to compare the effect of counseling based on PLISSIT and BETTER models on women’s sexual assertiveness after mastectomy.

Materials and Methods

Study design and setting

The present quasi-experimental study examined 78 mastectomized women who visited the Cancer Clinic of Omid Hospital in Mashhad from May 2021 to January 2022.

Study participants and sampling

The inclusion criteria of the study were as follows: informed consent to participate in research, literacy, being married, being at the age of 18–49, and passing at least one year after mastectomy. Sexual function score less than 28 based on the Female Sexual Function Index (FSFI)¹ questionnaire, non-use of drugs and alcohol in spouses, no use of drugs affecting sexual function by the person or her husband, not receiving sexual counseling during the last six months, not suffering from psychiatric illnesses, and moderate and severe depression, and lack of experience of accidents in the last one month.

Exclusion criteria were as follows: absence from a counseling session, recurrence of symptoms of breast cancer or its metastasis or other cancers, and death of the patient.

The sample size was obtained 42 per group, according to one study conducted by Karimi et al.[20] using the formula of the mean of two independent populations, the minimum sample size, and considering a confidence interval of 95% and test power of 80%. By considering the 20% probability of loss, the final sample size was 42 per group and a total of 84 individuals.

Sampling was performed after obtaining the approval of the University Ethics Committee and submitting a written letter of recommendation from the School of Nursing and Midwifery to the Breast Cancer Clinic of Omid Hospital and obtaining their consent. First, approximately 400 cases of breast cancer patients were studied from 2011 to 2020, and about 250 patients with primary conditions were selected. Then, they were contacted, and 84 patients with the inclusion criteria were selected, and written consent was obtained from them after providing the necessary information about the study and its objectives. They completed the questionnaires after receiving information on how to respond to each questionnaire and assuring them that the information would be confidential.

After selecting eligible individuals, the random allocation of individuals to the two consulting groups, BETTER and PLISSIT, was performed in random blocking using the table of random numbers from the website of www.randomization.com. The created sequences were recorded on small sheets and placed in sealed envelopes. The envelopes were opened according to the order of the arrival of the research units, and the assigned group was revealed. The final study was conducted on 78 individuals due to the loss of two units (three in the BETTER group due to death and metastasis and three in the PLISSIT group due to absence from counseling sessions) [Figure 1].

Figure 1.

Consort diagram of the study

Data collection tool and technique

The research tools included the demographic information form and the Hulbert index of sexual assertiveness (HISA), which were completed by the units before the intervention. The demographic information form included 37 questions prepared by studying new and valid references and articles. The HISA consisted of 25 questions with a score ranging from 0 to 100. The higher score indicated higher sexual assertiveness, and the lower score exhibited lower sexual assertiveness.[24] The reliability of the tool was 0.83 using Cronbach’s alpha coefficient in one study conducted by Azmoude et al.,[25] and it was 0.87 by the Cronbach’s alpha in the present study. The validity of all Questionnaires was confirmed by seven faculty members of the University of Medical Sciences.

Intervention procedure

In the PLISSIT counseling group, four 60–90-minute individual counseling sessions were held one week apart. First session: In a safe and trustworthy environment, the counselor allowed the clients to talk about sexual issues and express their concerns and problems. At this stage, the counselor began to talk to the patient and obtains complete information about the patient’s sexual issues by removing communication barriers. In fact, the first step was to accept the patient and validate his concerns. Second session: The counselor provided limited, real, and fact-based information in response to a question or potential sexual problems admitted by the clients. Providing limited information related to the client‘s concern can have a significant impact on his attitude and behavior. Limited information usually accompanies the first step, permission, and the counselor should only provide limited information that is directly relevant to the client. Despite providing a wide range of sexual information, evidence suggests that giving limited information about a client‘s problem can make a significant difference in a person‘s attitude. Third session: At this stage, the counselor offered specific and appropriate suggestions for the patient‘s sexual problem. The main solution to the problems at this stage is developed by the authorities’ decisions and the counselor’s guidance. These suggestions may include psychological, medication, or specific exercises. Fourth session: If the problem persisted, the clients were referred to a sex therapist or specialist [Table 1].

Table 1.

Sexual counseling content in the BETTER and PLISSIT groups

	Sessions	The aim of the counseling sessions	Counseling content based on the BETTER model
BETTER model	1	Bring up and explain sexual problems	- Talking to the patient and stating that she can talk easily - Discussion about the level of awareness about breast cancer and its side effects - Ask questions about sexual problems to identify the patient’s concerns
		*Consultant is the initiator of counseling.	- Question about how to express sexual desires with a spouse - Explain sex and its importance in the quality of sexual life - Explain sexual changes in breast cancer and its treatments, including mastectomy Homework: To monitor spontaneous thoughts in sexual situations, the patient was asked to ask herself what is going on in his mind when she notices a change in her mood. And write them down on a card until next week.
	2	Reassuring the client about the availability of counselors and telling coping strategies for sexual problems of breast cancer	- Reassuring the client to solve the problem or refer to special services in special cases - Reassuring that a counselor is available at all times to address sexual concerns - Examining the patient’s efficient and inefficient beliefs about sexual problems in breast cancer - Provide appropriate coping strategies and adaptive responses to disturbing thoughts requested in the previous session. - Examining dysfunctional beliefs about sex during breast cancer and mastectomy - Correcting the patient’s misconceptions Homework: The patient was asked to make a list of strengths and positive self-talk about his body.
	3	Focused education on sexual assertiveness	- Educate the patient about strategies to deal with sexual changes caused by breast cancer and mastectomy according to the patient’s problem - Teaching the use of alternative methods to have satisfactory sex - Training to express sexual needs and feelings - Learning to talk about how a woman feels about her body with her husband - Advising to play games and sexual fantasies Homework: Patients were asked to discuss the mental image of their body after a mastectomy with their spouse at home and to write down their feedback as homework for the next session.
	4	Record evaluations, interventions, and treatment outcomes	- Investigate how to deal with sexual problems - Assessing the client’s recovery from the consultant’s expectations - Recording and reflecting on all the experiences, feedback, and the degree of recovery of the client compared to the previous sessions
PLISSIT model	1	Allowing the patient to express sexual issues *The client initiates counseling.	- Ask open-ended questions about sex to start counseling - Identify the patient’s thoughts on sexual issues - Question about sexual and psychological changes due to mastectomy - Question about the reaction of the patient and her partner to the changes Homework: To monitor spontaneous thoughts in sexual situations, the patient was asked to ask herself what is going on in his mind when she notices a change in her mood. And write them down on a card until next week.
	2	Give limited information to the patient	- Explain the physical changes associated with breast cancer and its treatments - Explain the changes made in relation to the main problem mentioned by the patient - Provide appropriate coping strategies and adaptive responses to disturbing thoughts requested in the previous session Homework: The patient was asked to make a list of strengths and positive self-talk about his body.
	3	Specific suggestion to the patient with a focus on increasing sexual assertiveness	- Provide how to start sexual negotiation, sexual daring, and expressing sexual desires - Talk about sexual fantasies Advise to talk about affection, needs, and sexual desires with your spouse Homework: Patients were asked to discuss t mental image of their body after a mastectomy with their spouse at home and to write down their feedback as homework for the next session.
	4	Centralized treatment and patient referral	- Encourage the patient for her efforts and progress during the counseling period - Examining negative thoughts caused by damaged sexual self-concept and anxiety caused by these negative thoughts - Referral to a relevant specialist such as a sex psychotherapist or gynecologist

BETTER=Bring Up, Explain, Tell, Time, Education, Record, PLISSIT=Permission, Limited Information, Specific Suggestion, Intensive Therapy

In the BETTER counseling group, four 60–90-minute sessions of individual counseling were held one week apart based on the BETTER model as follows:

First session (Bringing Up and Explaining): The issue of sexual relations with the patient was raised, and then beliefs and sexual activity were assessed. The counselor explained the importance and impact of sexual issues on quality of life and reassured the patients to be comfortable in expressing their sexual issues. This was to help normalize sexual discourse and reduce the client‘s sense of shame. With the help of the counselor, the client realizes that she is not the only one in trouble, so she does not feel lonely. The counselor asked the client if she has ever talked to her spouse about this and what solutions she has sought to solve the sexual problems, thereby encouraging the client to talk. Second session (Telling and Timing): Informing and explaining the patients‘ sexual problems using available scientific references and paying attention to scheduling and discussing when the person is ready. Since sexual relation is an ongoing process, a counselor is available at any time to address the clients‘ concerns and answer their questions. Third session (Educating): The patients were educated about potential changes in sexual function due to cancer and its treatments, and recognized and corrected the clients‘ misconceptions about sex after cancer. Fourth session (Recording): important aspects of discussions, evaluations, and interventions were recorded [Table 1].

In both groups, the first session was held in the breast cancer clinic of Omid Hospital, and the next sessions were held via WhatsApp space by video call.

In addition, both groups provided the researcher with access to ask questions via mobile phone and WhatsApp chat.

The intervention was performed by the trained researcher with the support of a clinical psychologist in both groups. The validity of the counseling content was evaluated qualitatively by a survey of three faculty members related to the subject under study, including one reproductive health specialist, one psychologist, and sex therapist, and one oncologist.

Four weeks after the intervention, the HISA was re-completed by the research units.

Data analysis

After collecting and encoding the study data, they were inserted into the computer and analyzed by the Kolmogorov-Smirnov test, paired t-test, independent t-test, and Chi-square in SPSS 25. The significance level was considered to be 5%.

Ethical considerations

This two-group randomized trial was approved by the Research Ethics Committee of the University of Medical Sciences with the code IR.MUMS.REC.1399.681. Written informed consent was obtained from all participants, and they were assured that their information would be kept confidential.

Results

The mean ± standard deviation of women‘s age was equal to 41.3 ± 4.6 and 42.2 ± 4.3 years in BETTER and PLISSIT groups, respectively. The mean ± standard deviation of the duration of marriage was 18.8 ± 6.8 and 19.8 ± 6.8 years in BETTER and PLISSIT groups, respectively. The mean ± standard deviation of weight was 73.5 ± 12.3 and 69.8 ± 9.3 years in BETTER and PLISSIT groups, respectively. The two groups were homogeneous in terms of other demographic characteristics that were examined and compared before the intervention [Table 2].

Table 2.

Demographic characteristics of the participants in the BETTER and PLISSIT groups

Variable	BETTER group n (%)	PLISSIT group n (%)	P
Women’s educational level
Under diploma	10 (25.6)	10 (25.6)	0.867
Diploma	18 (46.2)	16 (41.0)
University	11 (28.2)	13 (33.3)
Spouse’s educational level
Under diploma	12 (30.8)	12 (30.8)	0.862
Diploma	15 (38.5)	13 (33.3)
University	12 (30.8)	14 (35.9)
Occupational status
Homemaker	29 (74.4)	31 (79.5)	0.122
Worker	6 (15.4)	1 (2.6)
Employed	4 (10.3)	7 (17.9)
Spouse’s occupational status
Worker	24 (61.5)	27 (63.9)	0.348
Employed	11 (28.2)	8 (20.9)
Retired	2 (5.1)	0 (0)
Unemployed	2 (5.1)	4 (10.3)
Separate room for sexual intercourse
Yes	27 (69.2)	23 (59)	0.345
No	12 (30.8)	16 (41)
Taking drugs affects sexual function
Yes	4 (10.3)	3 (7.7)	1.000
No	35 (89.7)	36 (92.3)
Chemotherapy
Yes	35 (89.7)	36 (92.3)	1.000
No	4 (10.3)	3 (7.7)
Radiation therapy
Yes	24 (61.5)	25 (64.1)	0.815
No	15 (38.5)	14 (35.9)
Hormone therapy
Yes	28 (71.8)	26 (66.7)	0.624
No	11 (28.2)	13 (33.3)
Vaginal dryness
Yes	28 (71.8)	34 (87.2)	0.092
No	11 (28.2)	13 (33.3)
Hot flash
Yes	36 (92.3)	33 (84.6)	0.481
No	3 (7.7)	6 (15.4)
Vaginal burning
Yes	14 (35.9)	15 (38.5)	0.815
No	25 (64.1)	24 (61.5)
Variable	BETTER group	PLISSIT group	T	P
Age	4.6±41.3	4.3±42.2	−0.860	0.393
Weight	12.3±73.5	9.3±69.8	1.524	0.132
Marriage date	6.8±18.8	6.8±19.8	−0.642	0.523

BETTER=Bring Up, Explain, Tell, Time, Education, Record, PLISSIT=Permission, Limited Information, Specific Suggestion, Intensive Therapy

Before the intervention, the mean score of sexual assertiveness was 46.7 and 43.07 in the BETTER and PLISSIT groups, respectively. The independent t-test indicated no significant difference (P = 0.253). Four weeks after the intervention, there was a significant difference in the mean scores of sexual assertiveness in both groups, but the difference was greater in the BETTER counseling group: 54.8 versus 48.6 (P = 0.027). After the intervention, sexual assertiveness increased by 8.07 and 5.58 points in the BETTER and PLISSIT groups, respectively. The independent t-test revealed a significant difference in sexual assertiveness scores (P = 0.026). The paired t-test indicated a significant difference in the sexual assertiveness scores of both groups compared to the time before the intervention (P < 0.001) [Table 3].

Table 3.

Mean (SD) of sexual assertiveness before and after the intervention in the PLISSIT and BETTER group

Sexual assertiveness	BETTER n=39	PLISSIT n=39	Result t-test
Before the intervention	46.7±14.6	43.07±13.4	P=0.253, t=1.151, df=76
After the intervention	54.8±11.5	48.6±12.5	P=0.027, t=2.255, df=76
Changes before and after the intervention between the groups	8.07±4.9	5.58±4.7	P=0.026, t=2.266, df=76
Result	P<0.001	P<0.001
Paired t-test	t=−10.192 , df=38	t=−7.357 , df=38

BETTER=Bring Up, Explain, Tell, Time, Education, Record, PLISSIT=Permission, Limited Information, Specific Suggestion, Intensive Therapy

Discussion

The present study aimed to compare the effect of sexual counseling based on BETTER and PLISSIT models on mastectomized women’s sexual assertiveness. The results demonstrated that the BETTER model had a more significant increase in sexual assertiveness than the PLISSIT model. It appears that the BETTER model can improve the conversation between the counselor and the client about sexual issues by creating a safe and intimate atmosphere since the BETTER model is client-centered and provides a wide range of sexual negotiations based on the client‘s schedule and information. Since there was no study to compare the effects of the above two models on sexual assertiveness in women with breast cancer, we reviewed the most relevant research in this field.

Jassim et al.[26] (2014) showed that some women consider themselves responsible for meeting their husband‘s sexual needs, despite their low sexual desire and try to meet their husband‘s sexual needs in all circumstances, and in fact, they may not pay attention to their sexual rights in this regard. Takahashi et al.[27] (2008) showed that women experience sexual problems after breast cancer treatment and experience a decrease in sexual arousal with their partners. In this study, sexual intercourse is affected by the psychological and physical improvement of women, sexual intercourse for couples, and fear of negative reaction by the spouse, which indicates the advice and assistance to patients in reducing existing problems and resumption of sexual intercourse.

One quasi-experimental study conducted by Akbari et al.[8] indicated that the four-factor psychotherapy had no effect on the sexual assertiveness of women with breast cancer. In this study, the sexual function scores of women were not screened, while only individuals with a score less than 28 in the FSFI were included in the present study. Akbari argued that the quality of women‘s sexual function was affected by cancer treatments and problems, such as body image change, atrophy, vaginal dryness, and numbness of the breasts, and this factor was an obstacle to sexual assertiveness and expression of sexual desire; hence, the use of special strategies and the participation of medical staff, along with psychotherapy appear necessary.

Nabila El-Sayed demonstrated that the implementation of the PLISSIT model was effective in improving sexual function, sexual satisfaction, and body image in breast cancer patients undergoing various treatments.[28] The findings of this study were consistent with those of the present study on the effectiveness of the PLISSIT model; however, one study conducted by Merghati Khoei, aiming at comparing sex counseling based on the PLISSIT model, and group sex education in Iranian women with breast cancer, indicated that although the PLISSIT model was an effective and well-known model, group counseling based on the sexual health model in the Iranian culture was more effective in improving sexual behaviors.[29] The results of this study were consistent with the results of the present study and somehow show the effectiveness of a counseling model such as BETTER, which is more in line with Iranian culture. Because group counseling also provides an opportunity for more interaction with peers, patients benefit from each other’s experiences and therefore express their problems more easily.[30]

Olcer et al.[31] (2021) also detected in their clinical trial that the “BETTER model”-based counseling was effective in raising and enhancing sexual health awareness and decreasing the existing sexual issues in women with breast cancer. Raising awareness about sexual changes after breast cancer and its treatments makes patients adapt to new sexual conditions, and therefore sexual performance has improved. According to Olcer, sexual counseling based on this model removes challenges and inefficient sexual beliefs and thereby improves sexual desires and relationships.

In many societies, women have difficulty in sexual assertiveness and have low self-esteem, and it is difficult for them to express their needs or maintain their independence in marital relationships. Therefore, counseling approaches, including BETTER, have been used to encourage couples to discuss sexual issues with each other and with healthcare providers. In this regard, Shahin et al.[32] found that nursing counseling with the BETTER model had a considerable effect on improving the sexual desire, sexual satisfaction, and psychological status of women with breast cancer. They indicated that although the BETTER model was designed for a specific group of patients and specialists, it had also been considered in other chronic diseases owing to its simplicity and focus on sexual discourse.

Zamani et al.[33] (2020) found that the BETTER model-based couple training and counseling were effective in improving the sexual satisfaction of women with type 1 diabetes, and the effect remained until three months after the intervention. The result was consistent with the result of the present study.

Karakas and Aslan.[21] found that the BETTER model improved infertile women’s sexual function and satisfaction. They stated that the BETTER model provided a suitable treatment environment for solving sexual function problems and helped women to express their sexual problems more easily. Their results were consistent with the results of the present study.

Karimi et al.[20] also compared the two counseling methods, BETTER and PLISSIT, in the sexual assertiveness of women with sexual problems after childbirth and found that the BETTER model was more effective than the PLISSIT model in increasing women’s sexual assertiveness, and their results were consistent with those of the present study.

The BETTER model‘s view about sexual issues is more than just having sex; it is a discussion of the role of sexuality, intimacy in life, and, most importantly, the recording of these conversations to expand and advance sexual discourse between the client and the counselor. In the BETTER model, the counselor starts a conversation, clarifies the importance of sexual issues to patients, encourages women to talk more about their problems, and attempts to break the taboo of discussing sexual problems, thereby eliminating the barriers to couples’ communication. Hence, it leads to a stronger desire for sexual assertiveness and ultimately increases the couple’s sexual satisfaction.

Limitations and Recommendations

The strength of the present study was that it first compared the two counseling methods, BETTER and PLISSIT, in women with breast cancer who underwent a mastectomy. The limitation of the present study was the absence of husbands in the study. Given the roles of husbands in couple communication and the importance of mutual communication in sexual intimacy, the presence of both couples in subsequent studies is recommended to make educational-counseling interventions more effective.

Conclusion

The BETTER model can have a considerable impact on increasing the sexual assertiveness of women with breast cancer by focusing on sexual relations, expressing sexual needs and preferences, paying attention to the sexual counseling timing, emphasizing the record of evaluations, and providing feedback. Thus, it can be used as an advanced easy-to-use framework for healthcare providers. It is suggested that a study similar to the present study be conducted in the presence of couples to compare BETTER and PLISSIT methods regarding sexual assertiveness.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Authors contribution

Raheleh Babazadeh supervised the project. Kowsar Hakami Shalamzari and Raheleh Babazadeh conceived the presented idea, designed the protocol, wrote and edited the manuscript, and are guarantors. Jamshid Jamali verified the analytical methods and performed the calculations. Negar Asgharipour and Ali Taghizadeh Kermani developed the theoretical framework, defined intellectual content, and contributed to the manuscript review. All authors discussed the results and contributed to the final manuscript.

Financial support and sponsorship

The authors would appreciate Mashhad University of Medical Sciences that supported the present study financially.

Conflicts of interest

There are no conflicts of interest.